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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 91-93

Heart transplant in India: Gleneagles Global experience


Department of Heart and Lung Transplantation, Gleneagles Global Hospital, Chennai, Tamil Nadu, India

Date of Submission27-Mar-2019
Date of Decision17-May-2019
Date of Acceptance25-Jun-2019
Date of Web Publication19-Aug-2019

Correspondence Address:
Dr. Ravi Kumar Ratnagiri
Department of Heart and Lung Transplantation, Gleneagles Global Hospital, 439, Cheran Nagar, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_19_19

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  Abstract 


Introduction: Heart transplant in India was started in 1994. The Indian transplant program differs from the West. In this study, we report the heart transplant experience from Gleneagles Global, Chennai. Materials and Methods: There were 55 patients who underwent a heart transplant during this period. Patients were induced with basiliximab, and the maintenance therapy was with tacrolimus, mycophenolate, and steroids. Results: Fifty patients underwent a heart transplant between 2017 and 2018. The age ranged from 21 to 66 years, and there were 45 males and 10 females. All patients were Class III and IV. Induction for transplant was with basiliximab 10 mg–20 mg. In 54 patients, tacrolimus was used, and low-dose tacrolimus plus everolimus 0.25 mg twice a day was given in five patients. Mycophenolate mofetil was given to all patients. Steroids were given to all patients. In 38 patients, renal function normalized by day 5, and in 12 patients, the renal recovery was delayed to day 10. Two patients needed postoperative dialysis. Three patients died of severe renal failure and sepsis. Fifteen patients had new-onset diarrhea in the 1st year with four having CMV[CE2] [CE2] antigen positivity, one with Clostridium difficile, and seven patients with diarrhea resolving with termination of mycophenolate. Four had Escherichia coli or Salmonella diarrhea which responded to oral antibiotics. One patient developed herpes zoster and another developed hepatic mucormycosis. Twelve patients developed sustained tremors and ten had severe headaches needing tricyclic antidepressants. Ten patients had episodes of leukopenia, eight of which resolved after temporary stoppage of valganciclovir and reduced dose of mycophenolate and two patients needed Granulocyte-colony stimulating factor therapy. Conclusions: This report covers the experience of 2 years and 55 patients. Mild side effects were noted in 30 patients after heart transplant. Side effects such as diarrhea, tremors, and headache were easily treated by clinical manipulation of drugs. Overall, 14 patients had significant bacterial or fungal or viral infections. Three patients died of sepsis ( first 15 days after transplant in 2 patients and 3–6 months in another).

Keywords: Gleneagles, heart, India, transplant


How to cite this article:
Ratnagiri RK, Dutta P, Attawar S. Heart transplant in India: Gleneagles Global experience. J Pract Cardiovasc Sci 2019;5:91-3

How to cite this URL:
Ratnagiri RK, Dutta P, Attawar S. Heart transplant in India: Gleneagles Global experience. J Pract Cardiovasc Sci [serial online] 2019 [cited 2019 Sep 15];5:91-3. Available from: http://www.j-pcs.org/text.asp?2019/5/2/91/264623




  Introduction Top


Heart transplant in India was started in 1994 at All India Institute of Medical Sciences (AIIMS). Since then, the number of centers doing a heart transplant has picked up slowly and the number of transplants has gone up rapidly, especially in the last decade. The Indian transplant program differs from the West with higher rates of infection, more rapid tapering of steroids, and lesser use of biopsies and more dependence on echocardiography. In the series published by the AIIMS,[1] infection has always been one of the major complications post transplant and with an increase in the experience of the transplant team and modification of the protocols, the complications including infection are seen to be reduced. In this study, we report the heart transplant experience from Gleneagles Global, Chennai [Figure 1].
Figure 1: Gleneagles Global Hospital

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  Materials and Methods Top


This is a report covering the heart transplant experience of Gleneagles Global, Chennai, from 2017 to 2018. Informed consent was taken from each patient. There were 55 patients who underwent a heart transplant during this period. Patients were induced using a standard protocol consisting of basiliximab, and the maintenance therapy was with tacrolimus, mycophenolate, and steroids.


  Results Top


Demographic details

Fifty patients underwent a heart transplant between 2017 and 2018. The age ranged from 21 to 66 years, and there were 45 males and 10 females. All patients were Class III and IV (25 were Class IV and 4 were on an assist device). Pulmonary vascular resistance ranged from 0.5 to 6.9 wood units. (Testing if required was done with injection milrinone or nitric oxide). The patient follow-up data up to 1 year are reported.

Treatment details

Induction for transplant was with basiliximab 10–20 mg (dose depending on body weight and general condition). In all patients, the CD25 level was checked on day 3, and the second dose of basiliximab was given only if CD25 was more than 3%. The second dose of basiliximab was given selectively in 15 patients.

In 54 patients, tacrolimus was used, and low-dose tacrolimus (level of 2–3 ng/ml) plus everolimus 0.25 mg twice a day was given in five patients. Mycophenolate mofetil was given to all patients. Steroids were given to all patients and tapered in 6 months in 45 patients and in the rest by 1 year.

Complications

In 38 patients, renal function normalized by day 5 allowing initiation of tacrolimus. In 12 patients, the renal recovery was delayed and tacrolimus could be started only on day 10 but without any side effects. Two patients needed therapy for azotemia with postoperative dialysis. Three patients died of severe renal failure and sepsis.

Fifteen patients had new-onset diarrhea in the 1st year. Of these, four had CMV antigen positivity and this resolved with intravenous ganciclovir in three. One had Clostridium difficile-positive diarrhea which was treated with intravenous vancomycin and metronidazole. In seven patients, diarrhea resolved with termination of mycophenolate. Four had  Escherichia More Details coli or  Salmonella More Details diarrhea which responded to oral antibiotics.

One patient developed herpes zoster responding to acyclovir, and another developed hepatic mucormycosis responding to amphotericin.

Twelve patients, all above 40 years of age, developed sustained tremors which resolved with beta-blockers or vitamins. Five required changing from tacrolimus to cyclosporine. Ten had severe headaches needing tricyclic antidepressants and five needed a change to cyclosporine.

Ten patients had episodes of leukopenia, eight of which resolved after temporary stoppage of valganciclovir and reduced dose of mycophenolate and two patients needed granulocyte-colony stimulating factor therapy.


  Discussion Top


This report covers the experience of 2 years and 55 patients. Mild side effects were noted in 30 patients after heart transplant. Side effects such as diarrhea, tremors, and headache were easily treated by clinical manipulation of drugs. Overall, 14 patients had significant bacterial or fungal or viral infections. Three patients died of sepsis ( first 15 days after transplant in two patients and 3–6 months in another).

All patients received induction therapy with basiliximab ranging from 10 to 20 mg, and subsequent doses were based on CD25 counts. The use of basiliximab[2],[3] allows immunosuppression to start and also allows delayed calcineurin initiation when there is delayed renal recovery after a heart transplant. Using CD25[4] counts helps adjust the basiliximab dose to minimize complications of infection posttransplant.

All patients received a triple regimen,[5],[6],[7],[8],[9] and steroids were tapered in 6–12 months in most of the patients. In most of the published series, 6-month and 1-year tapering has been found to be safe[10] though some transplant groups maintain on a very low dose of steroids.

Diarrhea was encountered and treated in 15 patients and was due to infections and drugs. In a study of more than 100 renal transplant patients with diarrhea for more than 7 days, diagnosis included bacterial infection (Campylobacter jejuni, Salmonella spp., and C. difficile), parasitic or protozoan infections, CMV infection, and other viral infections.[11],[12],[13],[14]

Tremors and headaches were the common neurological complications which are similar to other series.[15]


  Conclusions Top


In 2 years, 55 patients underwent a transplant, and complications included infection and transient renal dysfunction. All patients received induction therapy and the triple immunosuppression regimen. Complications included diarrhea, tremors, and headache. Three patients died of sepsis.

Ethics clearance

Informed consent taken from all patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Airan B, Singh SP, Seth S, Hote MP, Sahu MK, Rajashekar P, et al. Heart transplant in India: Lessons learned. J Pract Cardiovasc Sci 2017;3:94-9.  Back to cited text no. 1
  [Full text]  
2.
Kittipibul V, Tantrachoti P, Ongcharit P, Ariyachaipanich A, Siwamogsatham S, Sritangsirikul S, et al. Low-dose basiliximab induction therapy in heart transplantation. Clin Transplant 2017;31:e13132.  Back to cited text no. 2
    
3.
Manfredini V, Pettit S, Lewis C, Brahmbatt D, Parameshwar J, Kydd A. Extended use of rATG or basiliximab allows delayed CNI initiation in patients with renal dysfunction after heart transplantation. J Heart Lung Transplant 2017;36:S302-3.  Back to cited text no. 3
    
4.
Lin M, Ming A, Zhao M. Two-dose basiliximab compared with two-dose daclizumab in renal transplantation: A clinical study. Clin Transplant 2006;20:325-9.  Back to cited text no. 4
    
5.
Hollaran PF, Gourishankar S. Principals and overview of immunosuppression. In: Norman DJ, Turka LA, editors. Primer on Transplantation. Mt Laurel, NJ: American Society of Transplantation; 2001. p. 87-98.  Back to cited text no. 5
    
6.
Olivari MT, Kubo SH, Braunlin EA, Bolman RM, Ring WS. Five-year experience with triple-drug immunosuppressive therapy in cardiac transplantation. Circulation 1990;82:IV276-80.  Back to cited text no. 6
    
7.
Groetzner J, Meiser BM, Schirmer J, Koglin J, Scheidt W, Klauss V, et al. Tacrolimus or cyclosporine for immunosuppression after cardiac transplantation: Which treatment reveals more side effects during long-term follow-up? Transplant Proc 2001;33:1461-4.  Back to cited text no. 7
    
8.
Meiser BM, Pfeiffer M, Schmidt D, Reichenspurner H, Ueberfuhr P, Paulus D, et al. Combination therapy with tacrolimus and mycophenolate mofetil following cardiac transplantation: Importance of mycophenolic acid therapeutic drug monitoring. J Heart Lung Transplant 1999;18:143-9.  Back to cited text no. 8
    
9.
Mehra MR, Zucker MJ, Wagoner L, Michler R, Boehmer J, Kovarik J, et al. Amulticenter, prospective, randomized, double-blind trial of basiliximab in heart transplantation. J Heart Lung Transplant 2005;24:1297-304.  Back to cited text no. 9
    
10.
Khuu T, Kamath M, Smith J, Fuentes J, Cadeiras M, Nsair A, et al. Optimizing immunosuppression: Steroid weaning strategies in heart transplant (HT). J Heart Lung Transplant 2018;37:S91.  Back to cited text no. 10
    
11.
Maes B, Hadaya K, de Moor B, Cambier P, Peeters P, de Meester J, et al. Severe diarrhea in renal transplant patients: Results of the DIDACT study. Am J Transplant 2006;6:1466-72.  Back to cited text no. 11
    
12.
Stelzmueller I, Wiesmayr S, Swenson BR, Biebl M, Goegele H, Margreiter R, et al. Rotavirus enteritis in solid organ transplant recipients: An underestimated problem? Transpl Infect Dis 2007;9:281-5.  Back to cited text no. 12
    
13.
Stelzmueller I, Goegele H, Biebl M, Wiesmayr S, Berger N, Tabarelli W, et al. Clostridium difficile colitis in solid organ transplantation – A single-center experience. Dig Dis Sci 2007;52:3231-6.  Back to cited text no. 13
    
14.
Thielman NM, Guerrant RL. Clinical practice. Acute infectious diarrhea. N Engl J Med 2004;350:38-47.  Back to cited text no. 14
    
15.
Dogan U, Yaprak M, Dogan EA, Onac M, Yılmaz VT, Aydinli B. Cardiovascular and neurological complications in kidney transplant recipients: A focused appraisal of symptoms. Transplant Proc 2019;51:1101-7.  Back to cited text no. 15
    


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